Review Question - QID 106211

Action	Numeric Key	Letter Key	Function Key
Choose 1	1
Choose 2	2
Choose 3	3
Choose 4	4
Choose 5	5
Submit Response			Enter
Previous Question			Left Arrow
Next Question		N	Right Arrow
Open/Close Bookmode		C
Open Image			Spacebar

Polycystic Ovarian Syndrome QID: 106211 (M2.GN.13.255)

QID 106211 (Type "106211" in App Search)

A 27-year-old woman presents to her primary care physician for difficulties getting pregnant. She and her husband have been having unprotected intercourse once per day without success for the past year. She reports irregular menses. She is otherwise healthy and is not taking any medications. Her temperature is 98.0°F (36.7°C), blood pressure is 144/88 mmHg, pulse is 83/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical examination is notable for acne and the finding in Figure A. The patient has a notable abdominal pannus without any rashes noted. The patient is subsequently worked up with a TSH, prolactin level, and hysterosalpingogram, all of which are normal. She is instructed to lose weight by her physician and prescribed a medication to help her achieve pregnancy. What potential side effect must the physician warn the patient about?

Type & Select Correct Answer

Type in at least one full word to see suggestions list

Facial hair

1/35

Heterotopic pregnancy

26%

9/35

Lactic acidosis

29%

10/35

Increased insulin sensitivity

3/35

Loss of bone mineral density

31%

11/35

Select Answer to see Preferred Response

Review TC In New Tab

This woman has anovulation secondary to polycystic ovarian syndrome (PCOS) given her insulin resistance (as evidenced by acanthosis nigricans) and inability to get pregnant in the setting of irregular menses. Letrozole is the first-line treatment agent for restoring ovulation in women with PCOS and can cause decreased bone mineral density.

PCOS is commonly found in overweight women and is associated with insulin resistance and an elevated LH:FSH ratio. As a result, women have irregular menses and signs of hyperandrogenism. Symptoms include anovulation and those related to androgen excess, including acne and hirsutism. The most appropriate initial steps in management are weight loss, exercise, dietary changes, and metformin. If these measures fail, and improved glycemic control does not improve fertility, letrozole can be used. It is an aromatase inhibitor used to treat hormone receptor-positive breast cancer, but also can help with ovulation induction. By inhibiting estrogen production, it reduces the negative feedback of estrogen on the pituitary gland, thus resulting in an increase in follicle-stimulating hormone. However, due to its antiestrogen effects, it can cause loss of bone mineral density.

Figure A demonstrates the hyperpigmented skin of acanthosis nigricans which suggests insulin resistance.

Incorrect Answers:
Answer 1: Facial hair is a side effect of danazol which is used to treat symptoms for endometriosis. Endometriosis presents with dysmenorrhea, dyschezia, and dyspareunia as well as decreased fertility.

Answer 2: Heterotopic pregnancy is a side effect of clomiphene, which is second-line to letrozole in the medical management of PCOS-related infertility. It (and metformin) were previously first-line medications, but these medications appear to be less effective than letrozole for live birth rates. Side effects include ovarian hyperstimulation syndrome and heterotopic pregnancy.

Answer 3: Lactic acidosis is a side effect of metformin, which is a second-line medication (along with clomiphene) for treating women with PCOS who desire pregnancy.

Answer 4: Increased insulin sensitivity is a result of the lifestyle changes recommended in PCOS which include exercise, dietary changes, and weight loss. This treatment fundamentally corrects the underlying pathophysiology.

Bullet Summary:
Letrozole is the first-line medication for assisting PCOS patients with pregnancy, and one of its side effects is bone mineral density loss.